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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 22 of 22. This is the beginning of the thread.
Posted by pattisun16 on December 5, 2014, at 23:14:32
Now that I've tried Pamelor (ick) and am down to 20 mg of Celexa (most days), my internal med doctor gave me 20 mg of
Cymbalta to try for pain. I'm back on my Amitrptyline, I get migraines too. I was instructed to stop Celexa (been on that for 15 years, help my anxiety disorder well). Her claim: Cymbalta will work on my anxiety order and my pain and my migraines?
And cut the Amitryptyline down to 10 mg.
I take a lot for pain, 50 mcg of Fentanyl and then 4 Norco. Can't take NSAIDS.
ANYONE FAMILIAR WITH THESE MEDS, experience appreciated.
I also read that Cymbalta has a short life in your system, thus making it hard to go off of. Do you all remember Paxil--had to take Prozac to get off of that!!Thanks group!!
Patti in CA
Posted by Christ_empowered on December 6, 2014, at 12:45:22
In reply to Starting Cymbalta, how much til it helps pain?, posted by pattisun16 on December 5, 2014, at 23:14:32
hey....
...just wanted to say that I hope everything works out well for you. I think TCAs increase the blood levels of cymbalta, so you're probably getting more bang out of your 20mgs/Cymbalta than you might think. I'm glad you have docs who are willing to work with you. So many people with chronic pain are under-treated because of the DEA and also the way The Medical Establishment does things.
Anyway...good luck!
Posted by pattisun on December 6, 2014, at 13:55:56
In reply to Re: Starting Cymbalta, how much til it helps pain?, posted by Christ_empowered on December 6, 2014, at 12:45:22
I'm in a position that they aren't going to let me have more narcotic pain meds, even though my pain now us at 8, close enough to want to go to hospital but they would turn me away. I wish they could measure your pain scale. I knew when I was on "too many" pain meds when I had eye surgery in August and they sent me home with NO pain meds. I had to call my regular doctor the next day and it was 2nd day after surgery before I got pain reluef. So CYMBALTA---please work..
> hey....
>
> ...just wanted to say that I hope everything works out well for you. I think TCAs increase the blood levels of cymbalta, so you're probably getting more bang out of your 20mgs/Cymbalta than you might think. I'm glad you have docs who are willing to work with you. So many people with chronic pain are under-treated because of the DEA and also the way The Medical Establishment does things.
>
> Anyway...good luck!
Posted by Phillipa on December 6, 2014, at 17:25:37
In reply to Re: Starting Cymbalta, how much til it helps pain?, posted by pattisun on December 6, 2014, at 13:55:56
I think or feel that 60mg of cymbalta kept me from realizing I had back pain. As went off it it was there. I was lifting machine weights at the time in a gym. Now I see a neuro surgeon and I get PT. Nothing to be done for my back as too many things wrong with and no surgery for me. Also won't take pain meds as if I broke something I might not feel the pain. Phillipa
Posted by ed_uk2010 on December 7, 2014, at 14:24:57
In reply to Re: Starting Cymbalta, how much til it helps pain? » pattisun, posted by Phillipa on December 6, 2014, at 17:25:37
>won't take pain meds as if I broke something I might not feel the pain.
Pain meds are not anesthetics Phillipa, you'd still know you broke something.
Posted by pattisun on December 7, 2014, at 18:01:26
In reply to Re: Starting Cymbalta, how much til it helps pain? » Phillipa, posted by ed_uk2010 on December 7, 2014, at 14:24:57
> >won't take pain meds as if I broke something I might not feel the pain.
>
> Pain meds are not anesthetics Phillipa, you'd still know you broke something.
>
>
I UNDERSTAND his position...I'm at the end of my rope with this chronic pain. I hate how the tricyclics rewired my brain. I'm still messed up from them. It changed my personality and quite frankly messed up my sex life. I don't like being touched. It's got to be the effect of the meds.I hurt even when I had pain control, I would lay in bed most of the so I could go bowl on my league, I'd be screaming with pain (pain has volume) but I was doing what normal people do. I also went to the gym 2x week. I had about 2 days I had to stay quiet and lay down <sitting in a chair or standing hurts>
But even when I had enough narcotics to,control my pain, I would KNOW if I hurt myself!!I don't want more drugs but I am suffering with this pain, I have Cymbalta waiting for me at the pharmacy. I read the reviews on line from users. Not great for people with nerve impingement in their backs--down their legs, or hip bursitis I am meeting with a neurosurgeon too. I'm desperate..
Okay crew 'm going to get up my nerve to try it and I'll report back how it works.
Thanks for feedback.
Posted by Phillipa on December 7, 2014, at 18:11:38
In reply to Re: Starting Cymbalta, how much til it helps pain? » Phillipa, posted by ed_uk2010 on December 7, 2014, at 14:24:57
Ed I just don't want any other meds. Taking a 200mg of motrin for a headache once a day is my limit. I am considering tramadol as quite few posters combine it with SSRI? Phillipa
Posted by SLS on December 7, 2014, at 22:57:13
In reply to Re: Starting Cymbalta, how much til it helps pain?, posted by pattisun on December 7, 2014, at 18:01:26
> Okay crew 'm going to get up my nerve to try it and I'll report back how it works.
>
> Thanks for feedback.Good luck.
There are no guarantees, of course, but with antidepressants, it is very difficult to predict how they will affect someone. For treating pain disorders, Cymbalta (duloxetine) is for real. However, I don't know its therapeutic profile for specific pain syndromes. It is reported to be effective for fibromyalgia, neuropathies, and spinal stenosis.
Again - good luck.
- Scott
Posted by ed_uk2010 on December 8, 2014, at 3:55:27
In reply to Re: Starting Cymbalta, how much til it helps pain? » ed_uk2010, posted by Phillipa on December 7, 2014, at 18:11:38
> Ed I just don't want any other meds. Taking a 200mg of motrin for a headache once a day is my limit. I am considering tramadol as quite few posters combine it with SSRI? Phillipa
Very low doses of Motrin (such as you take) appear to cause very few side effects. Why would you want to replace it with tramadol?
Ibuprofen, adults...
Occasional doses - usually no side effects. One of the best tolerated NSAIDs overall. YMMV.
200mg up to three times a day - very low incidence of side effects. If taking every day, a gastro-protective med should be considered if at risk eg. over 65. Very low cardiovascular risk at this dose, if any.
400mg up to three times a day - low incidence of side effects but gastro-protective med should be added if taking regularly. Very low cardiovascular risk in the short term, possible small risk in the long term if taken continuously.
High dose ibuprofen eg. 600mg-800mg three or four times a day. Clearly higher incidence of adverse effects than lower dose. Generally suitable for short-term use only under medical advice. Long term use is associated with some cardiovascular risk.
In general, avoid total doses greater than 1200mg per day unless clearly necessary.
......................
Bear in mind that acetaminophen is very safe at the recommended dose. Do not overdose and you will be fine. There is a very big difference between the safety of a med at the recommended dose and its safety in overdose. For acetaminophen the two are entirely unrelated. Therapeutic doses have a very low incidence of side effects, but it is generally a less potent pain reliever than NSAIDs and has no anti-inflammatory effect.
Tramadol has a high incidence of side effects and withdrawal symptoms. Acetaminophen is clearly safer but if it doesn't help you can consider stronger meds.
Posted by SLS on December 8, 2014, at 6:16:17
In reply to Re: Starting Cymbalta, how much til it helps pain? » Phillipa, posted by ed_uk2010 on December 8, 2014, at 3:55:27
Hi Ed.
That was a nice synopsis.
> Ibuprofen, adults...
How do you feel about naproxen?
I find ibuprofen 400 - 600 mg effective for headache, but not for toothache. Naproxen reduced the pain of toothache remarkably well. I have not used either one for backache yet.
- Scott
Posted by Phillipa on December 8, 2014, at 9:05:56
In reply to Re: Starting Cymbalta, how much til it helps pain? » ed_uk2010, posted by SLS on December 8, 2014, at 6:16:17
Seriously I might not have been imagining it when I didn't have back pain on cymbalta and began to notice pain when stopped the med. Of course my osteo arthritis, spinal stenosis, bone spurs, and the two forms of curvature of spine might have just been getting to the point of hurting. I do know that for those with fibromyalgia it's a remarkably good med for pain.
As for the motrin, naprosen (sp?) problem is I get rebound headaches after only a day or two of the 200mg. I didn't know this about tramadol and the side effects. Since my Father & Grandfather both died at age 71 of heart attacks without ever knowing they had heart problems. I fear this also. Tylenol does nothing for me. Motrin is the only one that works. And I need the anti inflammatory properties. I see the neurosurgeon tomorrow.
Pattisun I hope the cymbalta works well for you. I know what it's like to be in pain. Phillipa
Posted by ed_uk2010 on December 8, 2014, at 10:09:18
In reply to Re: Starting Cymbalta, how much til it helps pain? » ed_uk2010, posted by SLS on December 8, 2014, at 6:16:17
> Hi Ed.
>
> That was a nice synopsis.
>
> > Ibuprofen, adults...
>
> How do you feel about naproxen?
>
> I find ibuprofen 400 - 600 mg effective for headache, but not for toothache. Naproxen reduced the pain of toothache remarkably well. I have not used either one for backache yet.
>
>
> - ScottFunnily enough, ibuprofen is extremely well established for dental pain, as it is for many other forms of acute pain. It's absorbed more rapidly than naproxen but the effects don't last as long. Both drugs are more effective than 10mg I/M morphine for post-op dental pain, which is particularly NSAID responsive and opioid resistant.... although oral opioids do produce an additive effect when combined with NSAIDs or acetaminophen, especially oxycodone (because it's well absorbed). Still, 600mg ibuprofen is similarly effective as 1g acetaminophen + 10mg oxycodone for post-op dental pain.... so I'd stick with the NSAID unless contraindicated. Single doses of NSAIDs in type of very 'acute' situation appear to cause FEWER reports of GI and other side effects than placebo, presumably because pts felt so much better due their pain being reduced, and there wasn't time for the NSAID to do any damage. Opioids on the other hand cause adverse effects immediately.
http://www.medicine.ox.ac.uk/bandolier/booth/painpag/acutrev/analgesics/leagtab.html
Naproxen appears to have a reasonably good cardiovascular safety profile for those needing an NSAID daily. Pain relief in arthritis may be more consistent than with the short-acting ibuprofen. Frequent BP measurements, serum chemistry profiles and CBCs are a good idea, the importance increases decade by decade (children rarely have side effects from NSAIDs, pts in their 90s can have a GI hemorrhage within days). Regular daily use of naproxen needs routine gastroprotection, except perhaps for very low risk pts eg. those in their 20s with no medical history. It causes more GI ulceration than ibuprofen. Unfortunately, proton pump inhibitors only protect the stomach and duodenum. They do not provide any protection lower down. NSAIDs can cause ulceration and mucosal damage in the small and the large intestine (diclofenac is a common culprit because it's excreted in bile). Aspirin/ASA is another culprit.
Pts on an NSAID + a PPI can have slowly falling hemoglobin levels and iron deficiency (ferritin down), suggestive of continuing gradual blood loss. Upper GI endoscopy may be negative. Small bowel studies usually show lesions in this situation (eg. capsule endoscopy). The lesions normally heal on stopping the NSAID. Oral misoprostol (Cytotec) 200mcg four times a day does provide some protection beyond the duodenum, but often causes diarrhoea and abdo pain! It's only suitable for men and post-menopausal women (misoprostol is abortifacient - see black box warning).
Ibuprofen is generally more suitable for acute pain than naproxen, but some people respond better to one than the other for unknown reasons. Naproxen is more suitable for arthritis and gout. Enteric-coated (gastro resistant) naproxen should probably be avoided for any severe acute pain indication, it can take forever to be absorbed.
The safety of NSAIDs in the long run is highly dose-dependent. Starting out with the full dose is often useful initially (except in the elderly) in order to relieve symptoms quickly, but it's best to taper down to the lowest effective dose for any chronic pain indication, or to use intermittently.
Celecoxib (Celebrex), a moderately selective COX-2 inhibitor, appears to have highly dose-dependent long term cardiovascular safety. 100-200mg per day seems fairly safe. 200mg twice a day less so. 400mg twice a day much less so. High doses are probably safe in the short term as an analgesic but it's no more effective than other NSAIDs for this purpose. Although celecoxib monotherapy causes fewer GI lesions than naproxen, it is not risk-free. It is now known that COX-2, and not simply COX-1 is needed for normal GI mucosal function. The newer selective inhibitors therefore still cause issues for some pts, and high risk pts may still need a PPI. Ibuprofen and naproxen are both somewhat COX-1 selective, as is aspirin. It used to be thought this was always a bad thing because COX-1 is needed for GI mucosal function and platelet function and it's mainly COX-2 which is expressed at the site of injury. Things have turned out to be far more complicated than initially thought... Take ibuprofen, not at all COX-2 selective but with a low GI risk at non-prescription doses.
Nabumetone is an interesting NSAID for chronic pain and arthritis. It's a non-acidic prodrug with apparently good GI and renal safety. It metabolite is marginally COX-2 selective. It's a rarely used drug but I have a friend on it with good effect after nothing else was tolerated.
Posted by ed_uk2010 on December 8, 2014, at 10:18:01
In reply to Re: Starting Cymbalta, how much til it helps pain?, posted by Phillipa on December 8, 2014, at 9:05:56
> Seriously I might not have been imagining it when I didn't have back pain on cymbalta and began to notice pain when stopped the med. Of course my osteo arthritis, spinal stenosis, bone spurs, and the two forms of curvature of spine might have just been getting to the point of hurting. I do know that for those with fibromyalgia it's a remarkably good med for pain.
>
> As for the motrin, naprosen (sp?) problem is I get rebound headaches after only a day or two of the 200mg. I didn't know this about tramadol and the side effects. Since my Father & Grandfather both died at age 71 of heart attacks without ever knowing they had heart problems. I fear this also. Tylenol does nothing for me. Motrin is the only one that works. And I need the anti inflammatory properties. I see the neurosurgeon tomorrow.
>
> Pattisun I hope the cymbalta works well for you. I know what it's like to be in pain. PhillipaThat's unfortunate about the rebound headaches. It usually takes a long time for NSAIDs to cause rebound headaches - this is much more common with opioids and triptans.
Did Cymbalta also help your headaches?
Posted by ed_uk2010 on December 8, 2014, at 10:20:30
In reply to Re: Starting Cymbalta, how much til it helps pain?, posted by pattisun on December 7, 2014, at 18:01:26
I really hope it helps you.
Sexual dysfunction is also common with Cymbalta but it may not be any worse than your current situation and if it helps the pain it could still be very worthwhile. If you take it long-term and then want to stop, Cymbalta needs to be tapered gradually. Let us know how you get on.
> > >won't take pain meds as if I broke something I might not feel the pain.
> >
> > Pain meds are not anesthetics Phillipa, you'd still know you broke something.
> >
> >
> I UNDERSTAND his position...I'm at the end of my rope with this chronic pain. I hate how the tricyclics rewired my brain. I'm still messed up from them. It changed my personality and quite frankly messed up my sex life. I don't like being touched. It's got to be the effect of the meds.
>
> I hurt even when I had pain control, I would lay in bed most of the so I could go bowl on my league, I'd be screaming with pain (pain has volume) but I was doing what normal people do. I also went to the gym 2x week. I had about 2 days I had to stay quiet and lay down <sitting in a chair or standing hurts>
> But even when I had enough narcotics to,control my pain, I would KNOW if I hurt myself!!
>
> I don't want more drugs but I am suffering with this pain, I have Cymbalta waiting for me at the pharmacy. I read the reviews on line from users. Not great for people with nerve impingement in their backs--down their legs, or hip bursitis I am meeting with a neurosurgeon too. I'm desperate..
>
> Okay crew 'm going to get up my nerve to try it and I'll report back how it works.
>
> Thanks for feedback.
>
>
Posted by Phillipa on December 8, 2014, at 19:54:57
In reply to Re: Starting Cymbalta, how much til it helps pain? » Phillipa, posted by ed_uk2010 on December 8, 2014, at 10:18:01
Ed wasn't getting headaches when took the cymbalta. So no idea if it would or not help. Phillipa
Posted by ed_uk2010 on December 9, 2014, at 1:22:43
In reply to Re: Starting Cymbalta, how much til it helps pain? » ed_uk2010, posted by Phillipa on December 8, 2014, at 19:54:57
> Ed wasn't getting headaches when took the cymbalta. So no idea if it would or not help. Phillipa
Are you sure you don't want to try it again? You have a lot of good things to say about Cymbalta. If you're currently on an SSRI perhaps you could replace it with Cymbalta.
Posted by phidippus on December 10, 2014, at 13:23:23
In reply to Starting Cymbalta, how much til it helps pain?, posted by pattisun16 on December 5, 2014, at 23:14:32
Cymbalta may help with your anxiety, pain and migraines.
Its a norepenephrine reuptake inhibitor and for some pushing norepenephrine causes anxiety.
Some studies suggest Cymbalta is good for arthritis pain.
All antidepressants can have some prophylactic affect on migraines.
Eric
Posted by SLS on December 10, 2014, at 21:32:03
In reply to Re: Starting Cymbalta, how much til it helps pain? » pattisun16, posted by phidippus on December 10, 2014, at 13:23:23
I might be misremembering, but I think the antidepressants that have the best antinociceptive properties are reuptake inhibitors of both serotonin (5-HT) and norepinephrine (NE).
http://www.sciencedirect.com/science/article/pii/S0028390804003156
I don't know why imipramine and clomipramine do not have reputations for treating pain. There is still much to learn about what these drugs do in the poorly understood brain. Elavil (amitriptyline) and Cymbalta (duloxetine) are the antidepressants best known to be antinociceptive, although fluoxetine (Prozac) is occasionally mentioned. Check out milnacipran, another reuptake inhibitor of both 5-HT and NE.
- Scott
Posted by phidippus on December 11, 2014, at 13:55:10
In reply to Re: Starting Cymbalta, how much til it helps pain? » phidippus, posted by SLS on December 10, 2014, at 21:32:03
I think its worth mentioning Tramadol here. Along with being an SNRI, it is also a mu-opioid agonist that's about as strong as codeine.
Eric
Posted by SLS on December 11, 2014, at 19:33:53
In reply to Re: Starting Cymbalta, how much til it helps pain? » SLS, posted by phidippus on December 11, 2014, at 13:55:10
> I think its worth mentioning Tramadol here. Along with being an SNRI, it is also a mu-opioid agonist that's about as strong as codeine.
Just the other day, my new doctor mentioned tramadol as a treatment for me, but I would have to discontinue Parnate in order to try it. So, she opted for low-dose naltrexone (LDN) at 4.5 mg/day. I'll probably take my first dose tonight. The next step might be to try intranasal ketamine. My doctor needs to investigate whether or not it is compatible with a MAOI. If I have to discontinue the Parnate in order to try ketamine, I will. High blood pressure is the concern.
Next week, I will probably add Deplin (L-methylfolate), Omega-3, and MitoQ (ubiquinone) - depending on my reaction to the LDN.
- Scott
Posted by phidippus on December 12, 2014, at 12:31:13
In reply to Re: Starting Cymbalta, how much til it helps pain? » phidippus, posted by SLS on December 11, 2014, at 19:33:53
What sucks about the Parnate is you can't augment it with anything useful. If you were on, say, Brintellix, you could take another AD or Tramadol for instance.
Eric
Posted by ed_uk2010 on December 13, 2014, at 3:53:39
In reply to Re: Starting Cymbalta, how much til it helps pain? » phidippus, posted by SLS on December 10, 2014, at 21:32:03
>I don't know why imipramine and clomipramine do not have reputations for treating pain. There is still much to learn about what these drugs do in the poorly understood brain. Elavil (amitriptyline)....
I think it's mainly a combination of custom and practice, and which drugs were chosen for clinical trials. Amitriptyline was chosen for many trials, possibly because it was also used to relieve insomnia associated with pain. Nortriptyline appears effective based on less evidence. I expect imipramine and clomipramine also work for certain types of chronic pain, but like amitriptyline, they are probably more suited to treating neuropathic pain than nociceptive pain. Not all types of neuropathic pain respond well, and treatment is often difficult. Diabetic peripheral neuropathic pain often responds better to ADs than other forms. Nociceptive pain, at least in the acute phase, isn't usually very responsive to antidepressants, more standard analgesics are often effective.
Among the types of nociceptive pain (which comes from peripheral pain receptors, not directly from nerves, the spinal cord or brain), are cutaneous/skin pain, somatic pain and visceral pain. Many types of pain are a complex combination, needing a equally complex combination of treatments. Somatic pain comes from the bones and joints, it responds particularly well to NSAIDs, and is one of their main uses. Visceral pain occurs when the internal organs are stretched, distended or damaged, it occurs especially in cancer and often responds best to opioids. Cutaneous pain responds to local anaesthetics and various combinations of other meds. NSAIDs are also useful for headaches (including migraine), menstrual pain, dental pain, acute post-operative pain and renal colic.
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